Healthy Skin Program - Department of Health

Transcription

D E PA R T M E N T O F H E A LT H
Healthy Skin Program
Guidelines for Community Control of Scabies, Skin Sores,
Tinea and Crusted Scabies in the Northern Territory
August 2015
Guidelines for the Community Control of Scabies, Skin Sores, Tinea and Crusted Scabies in the Northern
Territory
First edition February 2003
Second edition March 2010
Third edition August 2015
Contributors to the preparation of this document
This 2015 edition was revised by Dr Ella Meumann* with contributions from Professor Bart Currie†,
Nicola Slavin‡, Dr Dana Fitzsimmons§, Lesley Scott, RN* and A/Professor Vicki Krause*.
†
*Centre for Disease Control, Department of Health, Northern Territory, Infectious Diseases Physician Royal Darwin
‡
§
Hospital and Menzies School of Health Research, Environmental Health, Department of Health, Northern Territory, Top
end Health Services, Department of Health, Northern Territory.
Dr Christine Connors was the principle author of the Guidelines for Community Control of Scabies
and Skin Sores, September 1997 on which this document was originally based.
The 2003 and 2010 editions of Guidelines for Community Control of Scabies, Skin Sores and
Crusted Scabies in the Northern Territory were updated by Professor Bart Currie and Lesley Scott,
RN.
Centre for Disease Control©
Department of Health, Northern Territory 2015
This publication is copyright. The information in this report may be freely copied and distributed for
non-profit purposes such as study, research, health service management and public information
subject to the inclusion of an acknowledgement of the source. Reproduction for other purposes
requires the written permission of the Chief Executive of the Department of Health, Northern
Territory.
The Impetigo fact sheet included at Appendix 2 is based on material provided by the National Health
and Medical Research Council’s Staying Healthy. Preventing infectious diseases in early childhood
education and care services and is included with their permission.
Managing Households With Recurrent Scabies and Managing Crusted Scabies in Remote
Aboriginal Communities have been reproduced in this document with the permission of One
Disease.
This is an ePublication only available from Centre for Disease Control, publications web page:
www.nt.gov.au/health/cdc
General enquiries are welcome and should be directed to:
Centre for Disease Control
Department of Health
PO Box 40596
Casuarina NT 0811
Phone: 08 8922 8804
Facsimile: 08 8922 8310
For further information contact your regional Centre for Disease Control
Darwin: 08 8922 8044
Katherine: 08 8973 9049
East Arnhem: 08 8987 0357
Tennant Creek: 08 8962 4259
Alice Springs: 08 8951 7540
Department of Health is a Smoke Free Workplace
Territory
Contents
Section 1
1.1
1.2
Objectives ..................................................................................................................... 1
Rationale ....................................................................................................................... 1
Section 2
2.1
2.2
2.3
2.4
Background information ..............................................................................1
Definitions and clinical presentation ..........................................................2
Scabies.......................................................................................................................... 2
Crusted scabies............................................................................................................ 2
Skin sores (impetigo) ................................................................................................... 2
Tinea .............................................................................................................................. 2
Section 3
Skin checks, treatment and follow-up .........................................................4
3.1
3.2
Skin checks .................................................................................................................. 4
Treatment ...................................................................................................................... 4
3.2.1
Scabies .................................................................................................................... 4
3.2.2
Crusted scabies........................................................................................................ 5
3.2.3
Skin sores ................................................................................................................ 5
3.2.4
Tinea ........................................................................................................................ 5
3.3
Follow-up ...................................................................................................................... 6
3.4
Recurrent scabies ........................................................................................................ 6
Section 4
Diagnosis and management of crusted scabies ........................................7
4.1
Medical assessment and diagnosis ............................................................................ 7
4.1.1
Crusted scabies grading scale.................................................................................. 7
4.1.2
Investigations ........................................................................................................... 7
4.2
Treatment of crusted scabies cases and their contacts ............................................ 8
4.2.1
Treatment of cases ................................................................................................... 8
4.2.2
Treatment of contacts of crusted scabies cases ....................................................... 8
4.3
Treatment of house for crusted scabies cases .......................................................... 8
4.4
Follow-up ...................................................................................................................... 9
Section 5
Active surveillance and whole-of-community treatment .........................10
5.1
Planning ...................................................................................................................... 10
5.1.1
Initial community screening and treatment.............................................................. 10
5.1.2
Resources required ................................................................................................ 10
5.1.3
Education requirements of health staff ................................................................... 10
5.1.4
Ongoing program ................................................................................................... 11
5.2
Community involvement and education ................................................................... 11
5.2.1
Community participation ......................................................................................... 11
5.2.2
Community education ............................................................................................. 11
5.3
Baseline screening and community treatment......................................................... 11
5.3.1
Reasons for screening............................................................................................ 11
5.3.2
Who to screen ........................................................................................................ 11
5.3.3
How and where to screen ....................................................................................... 12
5.3.4
Documentation ....................................................................................................... 12
5.3.5
Whole-of-community treatment............................................................................... 12
5.4
Maintenance program ................................................................................................ 12
5.4.1
Follow-up and surveillance screening ..................................................................... 12
Territory
5.5
Evaluation ................................................................................................................... 13
Appendix 1
Scabies fact sheet............................................................................................. 14
Appendix 2
Impetigo (school sores) fact sheet .................................................................. 16
Appendix 3
Managing Households With Recurrent Scabies ............................................. 17
Appendix 4
Managing Crusted Scabies in Remote Aboriginal Communities................... 29
Appendix 5
Educational resource list ................................................................................. 52
Appendix 6
Equipment list for community screening and treatment ................................ 53
Appendix 7
Example spreadsheet for baseline screening................................................. 54
Appendix 8
Baseline screening and community treatment ............................................... 55
Appendix 9
Example spreadsheet for ongoing surveillance ............................................. 56
Appendix 10 Maintenance program ....................................................................................... 57
References .................................................................................................................................. 58
Territory
Section 1
1.1
Background information
Objectives
To provide a guideline for the community control of scabies, skin sores and tinea infection in remote
communities.
To reduce the prevalence of scabies, tinea, streptococcal skin sores and associated post
streptococcal illness in the Northern Territory (NT).
1.2
Rationale
Scabies is endemic in many remote Aboriginal communities, and underlies a large proportion of
streptococcal skin infections.1-3 Control of scabies is therefore critical in controlling streptococcal
skin infections and their sequelae.4-6 Outbreaks of acute post streptococcal glomerulonephritis
(APSGN) have been documented in the NT with large periodic outbreaks involving numerous
communities.7 APSGN occurs following streptococcal skin infection and is characterised by
oedema (most noticeably of the face), haematuria and hypertension. NT studies have shown that
children who have had APSGN are 6 times more likely to develop chronic kidney disease (CKD) as
adults.8,9 For more information see the Northern Territory Guidelines for Acute Post-Streptococcal
Glomerulonephritis.
The incidence of acute rheumatic fever (ARF) and prevalence of rheumatic heart disease (RHD) in
Top End communities are among the highest in the world.10-13 Low incidence of streptococcal
pharyngitis and high incidence of streptococcal skin infections and ARF in Indigenous communities
have led to the hypothesis that ARF can occur as a complication of streptococcal skin infection.
For further information see the Australian Guideline for Prevention, Diagnosis and Management of
Acute Rheumatic Fever and Rheumatic Heart Disease (2nd edition).
The high rate of streptococcal infection is therefore likely to be a significant contributing factor to the
high prevalence of CKD and RHD in the NT. Control of scabies is essential for prevention of
streptococcal skin infection.
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Section 2
2.1
Definitions and clinical presentation
Scabies
Scabies is a parasitic infestation of the skin caused by a mite, Sarcoptes scabiei (Appendix 1).14
Penetration of the skin leads to papules, vesicles and/or tiny linear burrows that contain the mites
and their eggs. Scabies papules and scratch marks are commonly found in the web spaces
between fingers and toes, and on the anterior surfaces of the wrists and elbows. Other common sites
include axillary folds, belt line, thighs, abdomen and buttocks. Burrows may not be seen. Infants
may have widespread lesions involving the head, neck, palms and soles. Itching is generally
intense and often more severe at night. Mites are transferred by direct contact with skin and can
burrow into the skin within 2.5 minutes. Transmission from undergarments and bedclothes
occurs only if these have been contaminated immediately prior to contact. The scabies mite that
affects dogs does not cause human infestation. Symptoms develop 2-6 weeks after exposure if
there has been no previous episode of scabies infection. The incubation period is 1-4 days in
individuals who have previously been exposed.
2.2
Crusted scabies
Crusted scabies is due to the same scabies mite. It occurs when the immune system fails to
control the infestation, and there is hyperproliferation of mites. In Central Australia, crusted
scabies has been associated with human T-cell lymphotropic virus 1 (HTLV–1) infection.15 A
large proportion of cases in the Top End have no identifiable immunological defect.16-18 People
with crusted scabies often have no itch and the rash manifests as scaling and crusting of skin,
often on buttocks, elbows and arms. Palms and soles of feet may be fissured. Cases can range
from mild with only a few patches, to severe infestation covering the entire body. It may be
misdiagnosed as other conditions such as psoriasis or fungal infection. Microscopic examination of
skin scrapings to detect the presence of mites and/or their eggs is required to make the diagnosis.
Individuals with crusted scabies are highly infectious to other people. They are also at high risk
of reinfection after initial successful treatment.18 Crusted scabies is associated with high morbidity,
and secondary skin sepsis may result in life threatening bacteraemia. Undiagnosed cases of
crusted scabies can lead to recurrent infection of treated household members.
2.3
Skin sores (impetigo)
Skin sores are almost always due to Group A Streptococcus (GAS) but Staphylococcus aureus can
also be isolated (see fact sheet, Appendix 2). The lesions start as pustules which subsequently
break down and form crusts. Skin sores often occur as a complication of scabies, and even though
there is a crust, this should not be referred to as crusted scabies. Eradication of GAS is important
to prevent post streptococcal disease including APSGN and ARF. GAS is usually the primary
pathogen so antibiotic treatment to cover S. aureus is usually not required for initial empirical
therapy.
2.4
Tinea
Tinea is a fungal infection that is caused by the dermatophytes Trichophyton, Epidermophyton and
Microsporum. It is usually spread between humans, but some tinea species have primary animal
hosts and therefore can be acquired from animals such as cats and dogs. In the Top End, the
majority of tinea infection is caused by a granular variant of Trichophyton rubrum, which is only
spread from person to person, has no animal reservoir and often causes extensive and severe
tinea of the body and nails.19 There are a number of names given to tinea disease, depending on
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the part of the body involved. Tinea can involve the body (tinea corporis, ringworm), feet (tinea
pedis, athlete’s foot), scalp (tinea capitis), groin folds (tinea cruris, jock itch) and nails (tinea
unguium, onychomycosis).
Tinea of the body starts as an itchy, scaly patch that spreads outwards with central clearing,
forming ring-shaped lesions. These can join together to form very large lesions. Tinea of the feet
presents as itchy, red fissures and erosions between the toes, but can progress to an extensive
scaly rash involving the rest of the foot. Tinea of the nails presents with white-yellow
discolouration, thickening and irregularity of the nails, with or without accumulation of flaky debris
between the nail and the nail bed. All forms of tinea can cause discomfort, there may be skin
breakdown as a result of scratching, and lesions may become secondarily infected with
streptococci and staphylococci.
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Section 3
Skin checks, treatment and follow-up
Effective diagnosis and treatment of scabies, skin sores and tinea requires a proactive approach.
The skin can be examined opportunistically when a patient presents for other reasons, and as part
of routine health checks. When scabies, skin sores and/or tinea are identified, it important to take
time to explain the correct method of application of cream and/or administration of the antibiotic
course, to encourage and facilitate completion of the treatment course, and to review the patient to
ensure there has been a clinical response.20-22 Adequate treatment of the household is also
important. When there are recurrent episodes of scabies within a household, a case management
approach is recommended.
3.1
Skin checks
A skin check is included in child health assessments at 6 weeks, 4, 6, 9, 12 and 18 months, and at
2, 3, 4 and 5 years of age (CARPA).16 This age group has the highest prevalence of scabies and
skin sores.23-25 Check the entire skin including the scalp.
Many communities will also have school age health screening programs. A skin check should be
included as part of this. In this age group, check hands, arms, legs, feet and waist. Only check the
rest of the skin if scabies or sores are noted, or if itching is present on other parts of the body.
An adult health check is recommended every 1-2 years from age 15 (CARPA).16
examination should be included as part of this.
3.2
A skin
Treatment
3.2.1 Scabies
•
•
•
•
Treat persons older than 2 months with 5% permethrin cream.16,20 Treatment should be applied
late in the afternoon or evening, left on overnight (8–12 hours) and washed off in the morning. It
must be applied from head-to-toe, ensuring the whole body is covered but avoiding the eyes and
mouth. Make sure that the cream covers between the fingers and toes, soles of feet, under
nails, behind ears, the groin, bottom and genitalia. Wear gloves while applying the cream to
others. This treatment should be repeated at 1-2 weeks, and a clinic recall is recommended to
ensure that this takes place
Treat infants less than 2 months of age with crotamiton 10% cream (Eurax) daily for 3 days.16
Leave cream on for 24 hours. Permethrin is not recommended for use on children less than 2
months of age
If there have been 2 or more presentations of scabies where permethrin 5% has not worked
AND reinfection is thought to be unlikely (child treated properly in clinic and all contacts treated),
treat with whole-body application of benzyl benzoate.16 Leave the lotion on for 24 hours, and
repeat treatment in 1 week. Do not use benzyl benzoate in children under 6 months of age. For
children 6-23 months dilute benzyl benzoate 25% with 3 parts water and for children 2-12 years
of age dilute with equal parts water. In children over 12 years of age and in adults use full
strength benzyl benzoate 25%. Benzyl benzoate occasionally causes severe skin irritation which
usually resolves in 15 minutes. In older children and adults if there is a reaction which settles
quickly, further doses of benzyl benzoate 25% can be diluted with equal parts water and
administered with or without an oral antihistamine
Oral ivermectin can also be used for treatment of typical (non-crusted) scabies where topical
treatments have failed or are contraindicated.16,20 Ivermectin should not be used in children
under 5 years of age or less than 15kg in weight. Ivermectin should not be taken during
pregnancy, and unless pregnancy testing is practical, it should not be given to females who
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•
•
could be pregnant. A medical consult is required prior to use of ivermectin, and an infectious
diseases physician can be consulted if the doctor is unfamiliar with this medication
All members of the affected household should be treated for scabies, even if they have no
clinical evidence of scabies. This is because scabies has a long incubation period, and other
household members may be infected but asymptomatic
Encourage the family to wash clothes and sheets with washing powder and dry in the sun, and
to air mattresses, pillows and blankets in the sun.
3.2.2 Crusted scabies
Management of crusted scabies is discussed in Section 4.
3.2.3 Skin sores
•
•
•
•
•
•
•
Treat with a single intramuscular (IM) dose of benzathine penicillin G (BPG)16,26
o 0-3 months, 3-6kg: 225mg (0.5ml)
o 3-6 months, 6-10kg: 337.5mg (0.8ml)
o 1-2 years, 10-15kg: 450mg (1ml)
o 4 years, 15-20kg: 675mg (1.6ml)
o 6 years and older, ≥20kg: 900mg (2.3ml)
Trimethoprim-sulfamethoxazole 4+20mg/kg/dose twice daily for 5 days is an alternative to
benzathine penicillin G16,27
Topical antibiotics including mupirocin are not recommended due to the often widespread nature
of sores and the potential for the emergence of antibiotic resistance
If there is concurrent scabies infection, permethrin 5% cream can be applied at the time
antibiotic treatment is given, including to the skin sores. There is no need to wait for healing, as
permethrin causes very little skin irritation
Children with skin sores should be excluded from childcare or school until appropriate antibiotic
treatment has been taken for at least 24 hours
Any sores on exposed skin should be covered with a watertight dressing. Dispose of dressings
such that they cannot be accessed by children
Do not touch sores directly. Wash hands before and after changing dressings, or if there is
inadvertent contact with the sore.
3.2.4 Tinea
•
•
Tinea of the body:
o Collect skin scrapings from the scaly edge of the area of tinea for fungal culture. Collect skin
scrapings by running a surgical blade held perpendicular to the skin across the affected area
using light pressure. Skin flakes should be collected in a sterile container (yellow topped
urine jar is suitable) and stored in the refrigerator. Be careful not to break the skin
o For small patches of ringworm apply miconazole 2% cream twice a day for 4-6 weeks
(including for 2 weeks after the rash has resolved)
o For widespread rash, give terbinafine oral daily for 2 weeks. See below regarding terbinafine
precautions and dosing.
Tinea of the scalp:
o Collect skin scrapings and pull some broken hairs for fungal culture
o Wash head with selenium sulfide 2.5% shampoo 3 times per week for 2 weeks
o If there is extensive scalp tinea, give terbinafine oral daily for 4 weeks. See below regarding
terbinafine precautions and dosing.
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•
•
•
Tinea of the nails:
o Collect clippings and collect material from under nail for fungal culture
o If the person is high risk (e.g. recurrent cellulitis, diabetes) or there is concern about
appearance, give terbinafine oral daily for 6 weeks for fingernails or 12 weeks for toenails.
See below regarding terbinafine precautions and dosing.
Precautions with oral terbinafine:
o Rare but serious side effects may develop, usually after 4 weeks of treatment, including liver
toxicity, blood abnormalities such as severe neutropenia and skin rash
o Check LFTs & FBE before treatment and at 2 and 4 weeks; discuss results with a medical
officer if these are abnormal. Therapy and monitoring can continue if there is only mild liver
function abnormality, but therapy must be stopped immediately if neutropenia develops
o Wait until after pregnancy and breastfeeding before treating, if possible.
Terbinafine dosing:
o 10-20kg, age 1-6 years, 62.5mg daily
o 21-40kg, age 7-12 years, 125mg daily
o >40kg, age >12 years, 250mg daily.
3.3
Follow-up
It is important to ensure that treatment of scabies, skin sores and tinea has led to cure. A clinic
recall 4 weeks after treatment for scabies treatment is recommended. If there is treatment failure
or reinfection, treatment of the case and household should be repeated. See below regarding
management of recurrent scabies.
3.4
Recurrent scabies
Where there are recurrent episodes of scabies in a household, a case management approach is
recommended. This is outlined in detail in the Managing Households With Recurrent Scabies,
2014 Edition guide developed by One Disease (Appendix 3).28 In summary, this approach includes
a home visit assessment for causes of scabies recurrence such as inadequate application of
cream/lotion, broken health hardware and exclusion of a crusted scabies contact. A treatment
approach should be planned in consultation with the family and may include a ‘Mini-Skin Day’
which involves treatment of multiple closely-related households. If the family agrees, help to
facilitate a clean-up of the house, and consider the use of an insecticide bomb for each bedroom.
See Section 4.3 Treatment of house for crusted scabies cases.
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Section 4
scabies
4.1
Diagnosis and management of crusted
Medical assessment and diagnosis
Crusted scabies is characterised by thickened, scaly, hyperkeratotic patches which are often not
itchy. Confusingly, skin sores often have a crust; this is not crusted scabies. Common sites for
crusted scabies include the buttocks, hands, feet, elbows and armpits. Consultation with an
infectious diseases physician regarding the diagnosis is recommended. Managing Crusted Scabies
in Remote Aboriginal Communities29 Appendix 4 provides pictorial information.
Wear gloves while examining patients with possible crusted scabies.
4.1.1 Crusted scabies grading scale
This scale18 assesses the severity of disease and guides treatment duration. Assess each of the
following parameters and add up the score.
A. Distribution and extent of crusting
1. Wrists, web spaces, feet only AND <10% total body surface area (TBSA)
2. Above plus forearms, lower legs, buttocks, trunk OR 10-30% TBSA
3. Above plus scalp OR >30% TBSA.
B. Crusting / shedding
1. Mild crusting (<5mm depth of crust), minimal skin shedding
2. Moderate (5-10mm) crusting, moderate skin shedding
3. Severe (>10mm) crusting, profuse skin shedding.
C. Past episodes
1. Never had it before
2. 1-3 prior hospitalisations for crusted scabies OR depigmentation of elbows and/or knees
3. ≥4 prior hospitalisations for crusted scabies OR depigmentation as above PLUS
depigmentation of legs/back or residual skin thickening/ichthyosis.
D. Skin condition
1. No cracking or pyoderma
2. Multiple pustules and/or weeping sores and/or superficial skin cracking
3. Deep skin cracking with bleeding, widespread purulent exudate.
ADD SCORE FOR A + B + C + D.
SCORE FOR GRADING: 4-6 = Grade 1, 7-9 = Grade 2, 10-12 = Grade 3.
4.1.2 Investigations
For each episode: skin scrapings (for scabies microscopy and fungal culture), FBE, UEC, CRP,
LFTs.
Consider: skin swab for microscopy and bacterial culture, blood cultures, nail clippings for fungal
culture.
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If not previously done: HIV Ab, HTLV-1 Ab, ANA, C3, C4, immunoglobulins, T-cell subsets.
Collect skin scrapings by running a surgical blade held perpendicular to the skin across the affected
area using light pressure. Skin flakes should be collected in a sterile container (yellow topped urine
jar is suitable) and stored in the refrigerator. Be careful not to break the skin.
4.2
Treatment of crusted scabies cases and their contacts
4.2.1 Treatment of cases
Consider treating Grade 1 cases in the community in consultation with an infectious diseases
physician. Grade 2 and 3 cases will need to be admitted to hospital. Treatment involves a
combination of oral ivermectin and topical treatments.
Ivermectin: 200mcg/kg/dose (3mg tablets which can be split, round dose up to nearest 1.5mg).
This should be given as directly observed therapy with each dose documented in the patient chart.
Ivermectin should be taken with a fatty meal.20
Grade 1: 3 doses on days 0, 1 and 7.
Grade 2: 5 doses on days 0, 1, 7, 8, 14.
Grade 3: 7 doses on days 0, 1, 7, 8, 14, 21, 28.
Topical treatments:
•
•
•
Benzyl benzoate 25% lotion (+/- tea tree oil 5%): Apply to the whole body second daily after
bathing for the 1st week, then 2-3 times weekly until cured. Apply from head-to-toe, ensuring the
whole body is covered but avoiding the eyes and mouth. Make sure that the lotion covers
between the fingers and toes, soles of feet, under nails, behind ears, the groin, bottom and
genitalia. Wear gloves while applying the lotion to others. Do not apply on same day as
Calmurid. Use permethrin 5% cream if benzyl benzoate is not available
Calmurid® (urea 10%, lactic acid 5% in sorbolene cream): This softens skin crusts and facilitates
shedding, thereby allowing better penetration of scabies lotion or cream. Apply after bathing on
the days not applying the topical scabicide. Calmurid® only needs to be applied to crusted or
thickened skin areas
The nail beds can serve as a reservoir for mites. Trim nails adequately, and if concerned about
concurrent tinea infection of nails, send clippings for fungal culture and consider treatment (see
Section 3.2.4 Tinea).
4.2.2 Treatment of contacts of crusted scabies cases
Treat all household and close contacts with single application of permethrin 5% cream (head to
toe), or crotamiton 10% cream if under 2 months of age.
All contacts who themselves have clinical scabies should complete a full treatment course as
described in Section 3.2.1 Scabies. Household contacts should be treated either the day of or the
day prior to the house being treated.
4.3
Treatment of house for crusted scabies cases
Scabies mites can only survive off the human host for up to around 3 days, but potentially for
several days longer if attached to shed skin in dark, moist environments. The homes of patients
with crusted scabies should therefore be treated once the patient begins treatment or is admitted to
hospital. With support, the patient’s family can take responsibility for household treatment. Clinic
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staff will need to liaise with the family to explain what needs to be done to help ensure that their
home is free of scabies mites.
Machine wash any clothes, bedding and towels used by the patient during the preceding 3 days on
a hot water cycle (50-60°C). If a hot machine wash is not available, items should be washed then
dried in the sun. Items that cannot be washed can be decontaminated by removing from any
contact for at least 3 days.
The house should be thoroughly vacuumed or swept then mopped to remove dust and skin
particles which could harbor mites. The vacuum bag or sweepings should be disposed of in an
outside rubbish bin. Mattresses and soft furnishings such as lounges should also be vacuumed or
swept. If possible they should also be left in full sun for at least several hours to help kill any
remaining mites. Pyrethroid-based insecticide sprays (available at community stores) can be used
to decontaminate mattresses and soft furnishings. A small amount of spray should be evenly
applied across the surface of the item. The directions on the label should be followed.
Fumigation of the house is not necessary if the house is thoroughly cleaned and clothes and
bedding are washed in hot water. However in severe cases and where the family wishes,
insecticide bombs containing pyrethroids can be used to help kill any scabies mites remaining in
the house. Insecticide bombs can be purchased by the family at the community store. In order for
the insecticide bomb to be effective all the windows in the house must be closed. Where windows
or louvres are missing, cardboard or plastic sheeting can be used to seal the house. The following
safety precautions need to be followed:
•
•
•
•
•
•
Read the label and follow directions carefully
Remove all children, pets, and toys from the house prior to treatment
Cover or remove food and utensils from the house prior to treatment
Leave the house immediately once the insecticide bombs have been released. Stay out of the
house until the time indicated on the label has passed, usually 2 to 4 hours
Upon returning open all windows and doors to air out the house
Keep any unused product away from children, for example, in a locked cupboard or shed.
The Environmental Health Branch of the Department of Health can provide further advice on the use
of insecticide bombs.
4.4
Follow-up
Regular follow-up of individuals with crusted scabies is recommended to ensure a durable
response to treatment.30 A suggested plan is outlined in Managing Crusted Scabies in Remote
Aboriginal Communities, 2014 edition,29 prepared by One Disease. This includes regular skin
examinations (fortnightly or monthly) and regular application of Calmurid. If there have been
multiple previous episodes of crusted scabies, consider initial fortnightly prophylactic benzyl
benzoate, with subsequent review to determine longer intervals between prophylactic benzyl
benzoate. If recurrences occur, consider possible causes such as inadequate treatment of
contacts or lotion/cream not applied adequately. Consider repeating household treatment.
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Section 5
Active surveillance and whole-ofcommunity treatment
Since the 1990s, some NT communities have implemented Healthy Skin Programs which involve
community education, active surveillance for scabies and skin sores, and whole-of-community
treatment for scabies.31-35 Some data suggest that this approach can lead to a significant decrease
in the prevalence of scabies and skin sores, however maintenance where there is a lower level of
prevalence is challenging. The degree of movement between communities is high, making reintroduction of scabies a major factor in scabies recrudescence and therefore regional coordination
is recommended. A committed approach with regular surveillance and repeat treatment of
households or whole community if required is important. The ability to carry out surveillance and
whole-of-community treatment will depend on clinic resources and other support, and some
communities may choose to undertake this only if scabies reaches particularly high prevalence, in
order to reduce scabies to a more manageable level.
A Healthy Skin Program can be divided into the following 5 phases:
•
•
•
•
•
Planning
Community involvement and education
Base-line screening and whole-of-community treatment
Maintenance
Evaluation
5.1
Planning
People to involve in the initial planning will vary from community to community but may include
health staff, council workers, women’s centre staff, school teachers and visiting health staff such as
environmental health officers and health promotion officers.
See Appendix 5, for a list of educational resources.
5.1.1 Initial community screening and treatment
A realistic timeframe for the initial community screening and treatment is required. This may need
up to 3 months of planning to allow for community awareness and education activities to take place.
Small communities may only require one day to screen and treat everyone, but larger communities
may need to allow up to a week of screening and treatment. Other community events should be
taken into consideration when deciding on the dates.
5.1.2 Resources required
•
•
•
Community population list
Extra supplies of scabies and skin sore treatments
Extra health staff and community members (if required) for baseline screening and treatment
5.1.3 Education requirements of health staff
Plan an education session for health staff to ensure everyone understands the issues and will
be delivering the same health message to the community. A discussion on the diagnosis of
scabies, crusted scabies and skin sores and appropriate treatment should be included.
10
Territory
5.1.4 Ongoing program
Ways of ensuring the sustainability of the program should be discussed. This should include
community education on how the lowered scabies rates will be maintained rather than just focusing
on the initial screening and treatment.
5.2
Community involvement and education
This phase may take up to 2 months depending on the size of the community, other community
events and available resources.
5.2.1 Community participation
Talk with different community organisations to identify community members who will support the
program and take the message to the community. They will include community leaders, elders,
council members, education staff, health boards, arts centre staff, women’s centre members,
outstation resource centres and others specific to your community. These people should be
involved in planning, the community treatment day and the ongoing maintenance program.
5.2.2 Community education
Plan to provide school and community education sessions and decide on the messages you want
to convey to the community. Schools may run a competition for children to develop posters about
scabies and skin sores. Local organisations often donate prizes, and the posters can be used for
community education. Communities can develop their own video story and show this locally.
Key messages for community education include:
•
•
•
•
•
•
•
The relationship between scabies, skin sores and kidney and heart disease
The success of the program in other communities
The importance of treating everyone, whether they have scabies or not
How to apply scabies creams and lotions
An ongoing program to keep scabies rates low
The importance of washing children to reduce skin infection
Health hardware to enable washing of children.
5.3
Baseline screening and community treatment
5.3.1 Reasons for screening
•
•
•
To establish the baseline scabies and skin sore prevalence in the community
To identify individuals with infected sores requiring treatment
To identify individuals with scabies requiring further application(s) of cream/lotion to complete a
full treatment course.
5.3.2 Who to screen
Children 0-3 years of age are an appropriate group for selective screening. These children have the
highest rates of scabies and skin sores, and are an easy group to access.23 Smaller communities
may decide to include children up to 5 years of age or even children up to age 15; this could be as
part of a school age health screening program.
It is not essential to screen adults, however all adults should be encouraged to be treated for scabies.
11
Territory
5.3.3 How and where to screen
A designated screening centre will need to be organised and well-advertised prior to the treatment
day. An appropriate centre may be the school, health clinic or women’s centre.
In larger communities health workers may decide to divide into teams to conduct mobile screening
while another team works at a screening centre. Refer people with other skin problems (for
example, tinea) to the clinic for treatment.
See Appendix 6 for a checklist of equipment required for screening and treatment.
5.3.4 Documentation
Accurate documentation is important as this will assist in follow up of cases and contacts. Clinic
staff should decide on the most appropriate record keeping method for the community (for
example, Primary Care Information System, Communicare) taking into account the need for follow
up of scabies, crusted scabies and household reinfections.
Infected sores should also be documented; these will be moist and have pus or a yellow/brown
crust. Do not record non-infected cuts, scratches or insect bites.
See Appendix 7 and Appendix 8 for a spreadsheet example for baseline screening and flow chart.
5.3.5 Whole-of-community treatment
Scabies whole-of-community treatment should be discussed and where appropriate offered at the
time of screening, with treatments as outlined in Section 3 above. Successful whole-of-community
treatments have included using only topical permethrin for all,32,33,36 or oral ivermectin for older
children and adults and topical permethrin for younger children and women who may be
pregnant.37,38 Health staff should demonstrate the correct way to apply the cream. When present,
skin sores will also need to be treated.
5.4
Maintenance program
An ongoing maintenance program is essential to ensure community scabies prevalence rates
are maintained at the lowered level. A return to previous high prevalence rates has been seen in
communities where a maintenance program has not been implemented. A maintenance program
involves:
•
•
•
•
Promotion of washing and maintenance of health hardware
Promotion of early presentation of scabies cases
Ensuring treatment of new cases and household contacts
Regular surveillance of young children to monitor prevalence.
See Appendix 9 and Appendix 10 for spread sheet example for follow-up screening and treatment,
and flowchart.
5.4.1 Follow-up and surveillance screening
All cases of scabies identified during the initial screening should receive a full treatment course
and be followed up as described in Section 3. Management of crusted scabies is discussed in
Section 4.
12
Territory
Community surveillance should be regular if possible and focused on identifying treatment
failure or reinfection. Surveillance following the community treatment day should be done
approximately 6 weeks later, and subsequently 2-4 times per year if resources allow. An
appropriate population for surveillance includes children 0-3 years of age. Smaller communities
may have capacity to include older children. It is important to document which children have had
scabies, skin sores and treatment such that households with frequent recurrences are identified.
See Section 3.4 and Appendix 3 regarding management of recurrent scabies.
5.5
Evaluation
After each survey:
•
•
Use graphs and pictures to present scabies rates to community decision-makers such as
councils, women’s centres, community elders and teachers
Write a short report on how the program is going and discuss it with the relevant health
service managers and program staff, environmental health officers and relevant stakeholders.
13
Territory
Appendix 1 Scabies fact sheet
14
Territory
15
Territory
Appendix 2 Impetigo (school sores) fact sheet
16
Appendix 3
Managing
Households
With Recurrent
Scabies
2014 EDITION
Breaking the cycle of recurrent scabies and skin sores
Document prepared by:
.org
Program design and people empowerment
17
Appendix 3
RECURRENT SCABIES
BREAKING THE CYCLE
Introduction
S cabies and related skin sores and chronic diseases (rheumatic heart and renal disease) affect many children
in remote communities and add to clinical workloads (e.g. data from Northern Australia showed 7 out of
every 10 children had scabies before age 1).
For some of these children the infection will be very hard to clear requiring multiple scabies treatments
and benzathine penicillin injections for resulting skin sores.
This document guides clinical and community staff on strategies to break the cycle of recurrent infections.
*Time spent on individual early case management of these children and households can lead to
improved outcomes, interruption of transmission and reduced workload for clinics in the long run.
Case Management Approach to recurrent scabies
T he reasons for recurrent scabies infections are complex and so a case management approach is needed to
break the cycle.
It is most important not to blame the mother or extended family.
o not label the mother or family non-compliant, to do so is to imply that the mother wants a sick child with
D
poor looking skin.
one well this public health activity can lead to rapid improvements in health and quality of life for the
D
family and bring the family, community and health centre closer together.
*All clinical protocols in this guide are based on the CARPA Standard Treatment Manual 6th Ed.
Please follow CARPA at all times.
INTRODUCTION | MANAGING CRUSTED SCABIES IN REMOTE ABORIGINAL COMMUNITIES | 2014 EDITION | 1
18
Appendix 3
RECURRENT SCABIES IN
A CHILD OR HOUSEHOLD
If a patient has 3 or more presentations with scabies +/- sores over
a period of 2 months we recommend investigating further.
Family well.
Leave creams.
Reinforce healthy
skin message
Recurrent
scabies in a household
If scabies persists,
reassess, consult CDC or
One Disease
1. Home-visit to assess
PAGE 3
2. Exclude
Crusted
Scabies
*If many
households have
scabies, consider
whole of community
Healthy Skin Day
(see CDC healthy skin
program guide)
5.Visit home for
follow-up in 1
week PAGE 9
PAGE 4
3. Planning
with family
PAGE 5
4. Household treatment
or Mini-skin day
PAGE 6-8
SUMMARY OF GUIDE | MANAGING HOUSEHOLDS WITH RECURRENT SCABIES | 2014 EDITION | 2
19
Appendix 3
1 VISIT FAMILY
AT HOME
Home visits are important to build trust and see the situation
the child is in. This cannot be done from the Health Centre.
Assess causes of recurrence
Engage families in finding solutions
Causes of recurrent scabies in a child
despite treatment:
1. Where does the mother of the child sit in
the family hierarchy? To ensure effective
household treatment, a senior member
of the household must be involved when
developing treatment plan with child’s
mother.
1. Treatment was not used correctly (i.e. not
full body application including hair/head,
creams left overnight and reapplied if hands
are washed, second treatment for cases one
week later- not required in contacts).
2. All household cases AND contacts did not
use the creams. Often only the child (and
mother) and symptomatic contacts use
creams but recurrences can occur from
contacts without clinical scabies who are less
likely to use treatment.
3. Household has an unmanaged case
of crusted scabies.
4. Less common: Permethrin failure or
transmission from bedding/clothes.
2. What other problems are going
on within the family? It may be more
effective to delay treatment day if there are
other crises present.
3. Is the health hardware in the house
working? Being an advocate with the Shire
or Council to get critical health hardware fixed
will build trust. It is important not to overpromise and to focus on broken taps, blocked
toilets, blocked drains.
4. Explain to the mother, family
members and particularly the
senior member of the household,
the importance of everyone using the scabies
creams to break transmission and allow
contacts to remain well.
1. VISIT AT FAMILY HOME | MANAGING CRUSTED SCABIES IN REMOTE ABORIGINAL COMMUNITIES | 2014 EDITION | 3
20
Appendix 3
2 EXCLUDE
CRUSTED SCABIES
Is there a known case of Crusted
Scabies or a member of the family
who may have it?
Ask:
Community staff and long-term clinical staff at
the health centre if any household members
have been diagnosed with crusted scabies or
had recurrent treatments in hospital in the past
Crusted scabies is a highly infectious
form of scabies that causes recurrent
outbreaks of scabies in households
and communities.
Check:
*See Managing Crusted Scabies Guide for
detailed steps in diagnosis and treatment
and contact the Infectious Disease team at
Darwin or Alice Springs hospitals.
L ook for thickened, scaly skin patches — may be
1–2 areas (e.g. bottom, hands, feet, shoulders) or
may cover whole body with thick/flaky crust.
S cale may have distinctive creamy colour, even in
dark skinned people.
Can look like tinea, psoriasis, eczema, dermatitis.
Often not itchy.
If crusted scabies is suspected —
medical review as soon as possible
2. EXCLUDE CRUSTED SCABIES | MANAGING CRUSTED SCABIES IN REMOTE ABORIGINAL COMMUNITIES | 2014 EDITION |
4
21
Appendix 3
3 PLANNING
WITH FAMILY
Household treatment options
1. Education only. Reinforce importance of “all of
household” treatment to senior household member
and supply creams
*Requires more effort but higher
chance of success
2. Clinic facilitated home based treatment of
all members of a household.
*Requires more effort but higher
chance of success
3. Mini skin day. Clinic facilitated treatment of 1-3
households in an extended family (households where
children/adults interact closely).
Considerations
epeated treatments and recurrences undermine confidence in the treatment and make future
R
engagement harder.
T herefore, where frequent treatments have been attempted, it may be appropriate to go straight to
the more intensive but effective mini-skin day (see 3. above).
3.PLANNING WITH FAMILY | MANAGING CRUSTED SCABIES IN REMOTE ABORIGINAL COMMUNITIES | 2014 EDITION | 5
22
Appendix 3
4 HOUSEHOLD
TREATMENT
Select medications to use
Treat all of the household (scabies cases and contacts) on day 1
Repeat for scabies cases only (not contacts) in 1 week.
First line treatments;
Consider;
Permethrin 5%
Benzyl Benzoate
Ivermectin
Instructions on use of permethrin
(as per CARPA scabies chapter).
Benzyl benzoate has a faster kill time
than permethrin and is preferred.
However, it can cause transient burning
sensation in some patients so give
warning and test on a patch of skin first.
Consider Ivermectin in males over
age 5 (NB: STROMECTOL (ivermectin)
is indicated for the treatment of
human
sarcoptic
scabies
when
prior topical treatment has failed or
is contraindicated. Treatment is only
justified when the diagnosis of scabies
has been established clinically and/
or by parasitological examination.
Without formal diagnosis, treatment is
not justified in case of pruritus alone.
At all times follow CARPA Guidelines.
o not use in children under 2 months
D
(use crotamiton e.g. Eurax).
se in children 2 months and over
U
and adults.
Instructions on the use of benzyl
benzoate 25% emulsion (as per CARPA
Apply thin layer of permethrin 5% cream scabies chapter).
on whole body including head and face
Apply topically to skin from the neck
— avoid eyes, mouth *.
down and leave on overnight.
Requires overnight application.
Do not use in children under 2 years
(use permethrin or if under 2 months
use crotamiton e.g. Eurax)
. C
hildren 2–12 years and sensitive
adults - dilute with equal parts water
(1:1).
Adults - apply directly.
enzyl benzoate may occasionally
B
cause severe skin irritation, usually
resolves in 15 minutes.
efore application, first test on a small
B
area of skin.
omprehensive coverage is critical to
C
effectiveness of control efforts. Certain
groups in the house may not want to
use creams, undermining control.
Consult a medical officer to be part
of the day to consider the use of
ivermectin in men.
Note:
D
o not give to women (ivermectin
cannot be used during pregnancy
and pregnancy testing is impractical
in community control programs).
D
o not give to children under 5.
Dosing of ivermectin :
*M
ake sure cream covers between fingers and toes, feet, including
soles of feet, under nails, buttocks. Leave on overnight and advise
to reapply after washing hands.
2 00mcg/kg rounded up to
nearest 3mg.
C
ontact with no clinical scabiesivermectin Day 1 only
Contact with suspected clinical scabies-ivermectin on Days 1 and 8.
4. HOUSEHOLD TREATMENT | MANAGING CRUSTED SCABIES IN REMOTE ABORIGINAL COMMUNITIES | 2014 EDITION | 6
23
Appendix 3
4 HOUSEHOLD
TREATMENT
Making sure everyone joins in
The application of creams is inconvenient but ensuring all household members use
the treatment is critical to the success. Make it a fun occasion and consider the
following tips to get everyone involved
Strategies for success
T ake time to get the support and interest of a senior household member. Explain the benefits in terms
of reduced sores and improved sleep. It is important to be flexible on the timing.
Select a day and time when most of household will be present (e.g. after school in the afternoon).
Involve senior members of household in helping others apply creams.
Start the application of creams during the home visit. Start by involving mothers to apply creams on children.
ften young children will be frightened. Start with an older person, apply on arms of mothers, staff to get
O
things started. After initial reluctance a tipping point is reached where everyone joins in. The trick is to stay
positive and keep going until you reach this point.
E ncourage older teens and adults to help each other with application. Highlight wearing creams as a sign of
their support for household health and wellbeing.
E nsure privacy and appropriate consent before applying creams. Parents should apply creams on children
and be present at all times.
Be discrete. The family may not want the whole community to know they are being treated for scabies.
Considerations
S creen children and record names of children with scabies. Refer other conditions to health centre
for treatment.
If the family agrees, organise a clean-up for the house. If possible supply cleaning products and equipment.
Encourage household to put bedding, clothes and mattresses in the sun.
I f it is requested by the family, set insecticide bombs in the house (available over-the-counter in
stores). Ensure families read and understand the nstructions.
Avoid other health promotion or clinical activities while doing a mini skin day.
24
Appendix 3
4 HOUSEHOLD
TREATMENT
Skin day checklist
Checklist:
1. Select appropriate day in consultation with senior members of the community.
2. Exclude crusted scabies cases.
3. E nsure sufficient clinical staff attending on the day (2-3 staff per household).
4. Take consumables: Permethrin, Benzyl benzoate (cups to mix BB 1:1 with tap water for children 2-12
years) and crotamiton cream, gloves, rubbish bags etc.
5. Take a sheet to record names of those with scabies to enter into health centre records. Use the sheet to
follow up for the 2nd dose of treatment 1 week later.
And most importantly – have fun.
This is a recurrent and common disease that is
associated with shame. Household treatment
places a significant burden on families so
focus on building rapport and engaging family
members to take ownership.
25
Appendix 3
5 FOLLOW UP
IN 1 WEEK
Follow-up in one
Engage
weekfamilies in finding solutions
If the scabies is resolved
If the scabies persists
ake sure a good supply of permethrin is left
M
with the family to treat visitors.
L eave the cream with the family leader (e.g.
senior female member).
Visit
the family at their home and discuss
the treatment (E.g. what went well and what
could be improved)
ffer more scabies cream and promote the use
O
of the cream with all contacts.
eview previous steps to check if something
R
else can be done to assist the family.
I f the scabies persists speak to a One Disease
representatives for program guidance.
At this stage it is more important than ever
not to blame the family. In these cases there
is normally something else going on and if
that can be resolved the scabies will often be
fixed by the family themselves. This may just
take time and patience.
Problem solve with the family.
They are part of the treatment team.
Consider a Healthy Skin Day If many
households have scabies
(see CDC Healthy Skin Program Guidelines and
call One Disease for advice)
5. FOLLOW UP IN ONE WEEK | MANAGING CRUSTED SCABIES IN REMOTE ABORIGINAL COMMUNITIES | 2014 EDITION | 9
26
Appendix 3
FOR MORE
INFORMATION
For clinical advice consult the CARPA Standard Treatment Manual or infectious diseases specialists via the
switchboards of Royal Darwin or Alice Springs hospitals.
For information on this document contact One Disease www.1disease.org or [email protected]
Useful Scabies Resources
NT CDC Healthy Skin Program Guidelines (planning a healthy skin day)
http://www.health.nt.gov.au/Centre_for_Disease_Control/Publications/CDC_Protocols/index.aspx
Flipchart – recognising and treating skin conditions (Menzies)
http://www.menzies.edu.au/icms_docs/162092_Recognising_and_Treating_Skin_Conditions.pdf
Developed by program strategy and implementation consultants, EveryVoiceCounts and the One
Disease team.
Thanks to Prof. Bart Currie for expert advice and pictures used.
Approved by the medical reference group of the East Arnhem Scabies Control Program.
.org
| MANAGING CRUSTED SCABIES IN REMOTE ABORIGINAL COMMUNITIES | 2014 EDITION | 10
27
Appendix 3
28
Appendix 4
Managing
Crusted Scabies in
Remote Aboriginal
Communities
2014 EDITION
Chronic disease case management of crusted scabies
to break the cycle of recurrences and transmission
Document prepared by:
.org
29
Appendix 4
CRUSTED SCABIES
AND ITS SIGNIFICANCE
What is it?
A severe form of scabies, caused when an individual’s immune system is not able to control mite
proliferation.
yper-infection develops, often with up to a million or more scabies mites. This is compared with 5-10
H
mites in simple scabies.
bnormally thick layers of keratinised cells in the stratum corneum, mixed with thousands of scabies
A
mites, eggs, mite faeces and shed skin. Hyperkeratosis can be localised or widespread.
In scabies endemic areas, crusted scabies must be treated as a chronic condition.
What is its significance?
I ndividuals with crusted scabies experience lower life expectancy, frequent hospitalisations and develop
secondary bacterial complications.
ousehold contacts of unmanaged crusted scabies have high risk of recurrent scabies, Strep A skin sores,
H
poor sleep, disruption of school and work. Strep A skin sores are associated with chronic heart and
renal disease.
rusted scabies is highly infectious and causes outbreaks of scabies. Effective management is essential
C
to the control of scabies in communities.
*All clinical protocols in the guide are based on the CARPA Standard Treatment Manual 6th Ed. Please follow CARPA at all
times.
WHAT IS IT | MANAGING CRUSTED SCABIES IN REMOTE ABORIGINAL COMMUNITIES | 2014 EDITION | 1
30
Appendix 4
SUMMARY
OF GUIDE
4. Chronic care plan
POSSIBLE
RECURRENCE
New case of
crusted scabies
suspected
Aim is to reduce recurrences and
impact of disease on patient,
household and community.
1. Diagnosis
Contact One Disease to
add name to crusted
scabies register.
Confirm crusted scabies
Consult Infectious
Disease Team at Royal
Darwin Hospital
(08 8922 8888) or
Alice Springs Hospital
(08 8951 7777).
PAGE 3-9
Critical part of
management.
PAGE 17 - 20
Key success
factor
Therapeutic rapport
and building capacity for
self-management
3. Household
treatment
With senior member of
house. PAGE 14-16 2. Patient
treatment
Develop treatment
plan with patient, consult
Infectious Disease Team
PAGE 10-13
SUMMARY OF GUIDE | MANAGING CRUSTED SCABIES IN REMOTE ABORIGINAL COMMUNITIES | 2014 EDITION | 2
31
Appendix 4
1 DIAGNOSIS
Diagnosis can be difficult
Prompt and correct diagnoses of crusted scabies is vital. Misdiagnosis results in unnecessary and
expensive treatment and puts the patient on an unnecessary chronic condition management plan. Time
spent properly confirming diagnoses will save time and resources in the future.
To make a positive diagnosis you must confirm a & b, (and ideally c & d):
A. Identify / confirm clinical appearance
B. Take skin scrapings
C. Audit patient clinical files
D. Conduct tracing
1. DIAGNOSIS | MANAGING CRUSTED SCABIES IN REMOTE ABORIGINAL COMMUNITIES | 2014 EDITION | 3
32
Appendix 4
1 DIAGNOSIS
A Identify / confirm clinical appearance
Characteristic crusted skin patches:
Thickened, scaly skin patches. Often not itchy.
Often, but not always on buttocks, hands, feet, elbows and armpits
Scale may have distinctive creamy colour
Do not confuse with tinea, psoriasis, eczema or dermatitis as it may look similar.
Specialist diagnosis recommended:
T he diagnosis can be difficult. Always consult Infectious Disease Team via switch at Royal Darwin
Hospital on 08 8922 8888 or Alice Springs Hospital on 08 8951 7777.
s underlying immune deficiency can be cause of the disease further testing is warranted. Discuss with
A
infectious disease specialist.
Alert:
Staff and carers should practice infection control procedures including wearing disposable gloves.
Take care not to come in contact with scabies-containing fomites such as bedding or seating.
you think you have been exposed to scabies during the course of your work you may wish to apply a
If
scabicide cream preventatively (e.g. benzyl benzoate) to exposed areas.
33
Appendix 4
1 DIAGNOSIS
A Clinical appearance
Hyper-keratotic (thick, scaly, cream coloured) areas with significant skin
shedding (highly infectious).
Crusted scabies cannot
be excluded unless
buttocks are seen
(common area for crusts).
Depigmented areas of skin. This is evidence of repeated recurrences of past
crusting signifying chronicity and severity (add to grading scale pg 12).
Crusted scabies in a patient with claw hand from
past leprosy.
Crusted scabies of the toes and feet.
34
Appendix 4
1 DIAGNOSIS
AC
linical Appearance: Common errors
It is common for immediate contacts of patients with crusted scabies to be misdiagnosed. See p9 for
more information about contact tracing.
Misdiagnosing crusted sores (scabs, dry exudate) and or fungal as crusted scabies
Scabies papules.
Crusted sores and fungal
infection.
This is not crusted scabies.
Scabies vesicle.
This is simple scabies with localised epidermal thickening.
Crusted sores.
This is not crusted scabies.
35
Appendix 4
1 DIAGNOSIS
B S kin scrapings
Collection
1. Identify an area of suspected crusting (thickened, scaly skin).
2. Gently use the sharp side of a sterile scalpel held at a 90º angle to scrape loose flakes of skin into a sterile
urine collection jar. If true crusting is present skin should be easily collected.
Collection technique
Collect loose flakes of skin from areas of
suspected crusting
on’t rush the process. The more skin collected the greater the chance of confirming the diagnosis.
3. D
A few pieces of skin may be sufficient, but collect as much skin as possible.
4. If skin is not readily falling into the jar crusted scabies is less likely.
5. Do not cut or injure the skin. Infection and sepsis is a real risk in these patients.
6. Send collected sample to lab for testing. Make sure to request testing of scabies mites.
7. A
bsence of mites from skin scrapings does not rule out the possibility of crusted scabies. If results are
positive this greatly increases the likelihood of crusted scabies.
36
Appendix 4
1 DIAGNOSIS
CA
udit patient clinical files
eople who develop crusted scabies once are vulnerable to redeveloping the disease for life. They
P
often have multiple admissions for crusted scabies going back many years. With clinic staff turnover
being high, this knowledge can be lost.
Review electronic notes for past diagnoses and or hospitalisation for crusted scabies.
If available review paper notes for past diagnoses and or hospitalisation for crusted scabies.
Add past crusted scabies to grading scale pg 11.
Magnified scabies mites.
37
Appendix 4
1 DIAGNOSIS
DC
ontact tracing
Crusted scabies patients are super spreaders/core transmitters of scabies.
Where outbreaks of scabies or recurrent scabies occur in families, look for crusted scabies.
Close contacts of crusted scabies can exhibit severe scabies rashes and may have been misdiagnosed
with crusted scabies (crusted scabies like condition).
Condition can mimic crusted scabies and may be positive for mites on scrapings.
If primary and secondary contacts have little to no scabies crusted scabies is unlikely.
hildren with 10 or more interactions with the local health centre for scabies in a one year period
C
strongly indicate uncontrolled crusted scabies in their household.
Family
Crusted
scabies
patient
L ikely to share a bed/bedroom with
crusted scabies patient.
Primary contacts
(crusted scabies
like condition)
Exposed to thousands of mites.
ondition can mimic crusted scabies
C
including high mite loads on scrapings.
ot true crusted scabies. May be
N
misdiagnosed as crusted scabies.
L ive in or frequently visit same location
as crusted scabies patient.
Secondary contacts
evelops severe scabies and sores.
D
This is particularly true for young
children in the house.
Infrequent contact with case.
Tertiary contacts
Develop regular scabies and sores.
Have scabies rates higher than expected.
Community
38
Appendix 4
2 PATIENT
TREATMENT
2. PATIENT TREATMENT | MANAGING CRUSTED SCABIES IN REMOTE ABORIGINAL COMMUNITIES | 2014 EDITION | 10
39
Appendix 4
2 PATIENT
TREATMENT
Grade Disease
Choose best option in each category and add numbers to get score
a: Distribution and extent of crusting
1. W
rists, web spaces, feet only — less than 10% Total Body Surface Area (TBSA)
2. A
s above plus forearms, lower legs, buttocks, trunk OR 10–30% of TBSA
3. A
s above plus scalp OR more than 30% TBSA
b: Crusting/Shedding
1. M
ild crusting (less than 5mm deep), minimal skin shedding
2. M
oderate crusting 5–10mm deep), moderate skin shedding
3. S evere crusting (more than 10mm deep), profuse skin shedding
c: Past episodes
1. N
ever had it before
2. 1
–3 prior hospitalisations for crusted scabies OR depigmentation of elbows, knees
3. M
ore than 4 prior hospitalisations for crusted scabies OR depigmentation as above PLUS
legs/back or residual skin thickening/ scaly skin (ichthyosis)
D: Skin conditions
1. N
o cracking or pus in skin (pyoderma)
2. M
ultiple pustules and/or weeping sore and/or superficial skin cracking
3. D
eep skin cracking with bleeding, widespread purulent exudates
Score:
4 – 6
= Grade 1
7 – 9
= Grade 2
10 – 12
= Grade 3
Depigmentation
Severe crusting
(more than 10mm deep),
profuse skin shedding
40
Appendix 4
2 PATIENT
TREATMENT
Working together
Patients suffer life-long stigmatisation and blame and often avoid health services
1. Identify any fears
the patient has which
could be barriers to
treatment
Common concerns of crusted scabies patients:
H
ospitalisation in an isolation ward.
Worry about onerous burden involved in whole of household
treatment.
Failure of previous treatments reduces motivation to try again and
again.
2. Work with patient
and family to develop
a treatment plan they
are comfortable with
Common mistakes in case management of
crusted scabies:
Failing to take time to visit families at home.
Focusing on clinical protocols before establishing rapport.
N
ot spending time explaining the disease, its chronicity and the
importance of compliance to break the cycle of recurrences.
Not taking time to win the support of a senior member of the
household to ensure compliance with household treatment.
While it can be frustrating, do not label the patient or family noncompliant. The family has to be part of the treatment team.
41
Appendix 4
2 PATIENT
TREATMENT
Ideally all patients should be admitted to hospital for treatment (especially Grades 2-3). This is due to risk
of sepsis, re-infection from fomites and contacts and infection control. For first diagnosis hospitalisation
is especially important as possible underlying immune deficiencies needs to be investigated.
For community based treatment of crusted scabies at home it is very important that the topical therapy is
supervised by the health staff-preferably all doses but especially the first.
Community based treatment:
1. G
ive ivermectin single dose on days 0, 1, 7. Give with food or milk for better absorption. (N.B. Longer
treatment needed for Grade 2-3. Contact Infectious Disease Team at Royal Darwin Hospital on 08 8922
8888 or Alice Springs Hospital on 08 8951 7777).
2. G
ive topical agents (critical part of treatment):
L actic acid and urea cream (e.g. Calmurid) every second day to soften skin. Don’t use on the
same day as scabies cream. Applying lactic acid/urea and the next day a warm soaking bath/
shower and scrubbing with a sponge is critical for removal of crusts.
Benzyl benzoate 25% with/without tea tree oil OR permethrin every second day for the first
week.
Dilute benzyl benzoate for children under 12.
THEN twice a week until well. Put on after soaking in the bath/shower.
3. P
atients must be seen daily , linen and clothes must be washed and sunned daily during
household treatment.
42
Appendix 4
3 HOUSEHOLD
TREATMENT
Creating a scabies free household
H
ome visits are critical to gain trust, understanding and
treatment success.
I t is important to ensure the household is scabies free to prevent recurrences in the crusted scabies atrisk person.
The cycle of transmission can be broken: consistent application of this chronic disease approach improves
quality of life for households and reduces clinical workloads.
2. GRADING AND PATIENT TREATMENT | MANAGING CRUSTED SCABIES IN REMOTE ABORIGINAL COMMUNITIES | 2014 EDITION | 14
43
Appendix 4
3 HOUSEHOLD
TREATMENT
Select medications to use
Treat all of the household (scabies cases and contacts) on day 1
Repeat for scabies cases only (not contacts) in 1 week.
First line treatments;
Consider;
Permethrin 5%
Benzyl benzoate
Ivermectin
Instructions on use of permethrin
Benzyl benzoate has a faster kill time
than permethrin and is preferred.
However, it can cause transient burning
sensation in some patients so give a
warning and test on a patch of skin first.
Consider ivermectin in males over age
5 (NB: STROMECTOL (ivermectin) is
indicated for the treatment of human
sarcoptic scabies when prior topical
treatment has failed or is contraindicated.
(as per CARPA scabies chapter).
o not use in children under 2 months
D
(use crotamiton e.g. Eurax).
se in children 2 months and over
U
and adults.
Instructions on the use of benzyl
benzoate 25% emulsion (as per CARPA
Apply thin layer of permethrin 5% cream
scabies chapter).
on whole body including head and face
Apply topically to skin from the neck
— avoid eyes, and mouth.
down and leave on overnight.
Requires overnight application.
Do not use in children under 2 years
(use permethrin or if under 2 months
use crotamiton e.g. Eurax).
hildren 2–12 years and sensitive
C
adults -dilute with equal parts water
(1:1).
Adults – apply directly.
enzyl benzoate may occasionally
B
cause severe skin irritation, usually
resolves in 15 minutes.
efore application, first test on small
B
area of skin.
Treatment is only justified when
the diagnosis of scabies has been
established clinically and/or by
parasitological examination. Without
formal diagnosis, treatment is not
justified in the case of pruritus alone. At
all times follow CARPA Guidelines.
omprehensive coverage is critical to
C
effectiveness of control efforts. Certain
groups in the house may not want to
use creams, undermining control.
onsult a medical officer to be part
C
of the day to consider the use of
ivermectin in men.
Note:
D
o not give to women (as ivermectin
cannot be used during pregnancy
and pregnancy testing is impractical
in community control programs).
D
o not give to children under 5.
Dosing of ivermectin :
Make sure cream covers between fingers and toes, feet including soles of feet,
under nails, buttocks. Leave on overnight and advise to reapply after washing
hands.
2
00mcg/kg rounded up to nearest 3mg.
C
ontact with no clinical scabiesivermectin Day 1 only
C
ontact with suspected clinical scabiesivermectin on Days 1 and 8..
44
Appendix 4
3 HOUSEHOLD
TREATMENT
Making sure everyone joins in
The application of creams is inconvenient but ensuring all household members use
the treatment is critical to the success. Make it a fun occasion and consider the
following tips to get everyone involved.
Strategies for success
ake time to get the support and interest of a senior household member. Explain the benefits in terms
T
of reduced sores and improved sleep. It is important to be flexible on the timing.
S elect a day and time when most of household will be present (e.g. after school in the afternoon).
Involve senior members of household in helping others apply creams.
Start the application of creams during the home visit. Start by involving mothers to apply creams on
children.
Often young children will be frightened. Start with an older person, apply on arms of mothers, staff to
get things started. After initial reluctance a tipping point is reached where everyone joins in. The trick
is to stay positive and keep going until you reach this point.
E ncourage older teens and adults to help each other with application. Highlight wearing creams as a
sign of their support for household health and wellbeing.
E nsure privacy and appropriate consent before applying creams. Parents should apply creams on
children and be present at all times.
Be discrete. The family may not want the whole community to know they are being treated for scabies.
Considerations
S creen children and record names of children with scabies. Refer other conditions to health centre
for treatment.
If the family agrees, organise a clean-up for the house. If possible supply cleaning products and equipment.
Encourage household to put bedding, clothes and mattresses in the sun.
I f it is requested by the family, set insecticide bombs in the house (available over-the-counter in stores).
Ensure families read and understand instructions.
Avoid other health promotion or clinical activities while doing a mini skin day.
45
Appendix 4
4 CHRONIC
CARE PLAN
Maintenance plan to prevent recurrences once patient
and family are treated and free of scabies.
4. CHRONIC CARE PLAN | MANAGING CRUSTED SCABIES IN REMOTE ABORIGINAL COMMUNITIES | 2014 EDITION | 17
46
Appendix 4
4 CHRONIC
CARE PLAN
Essentials
E nsure a regular supply of creams (e.g. 2 benzyl benzoate, 4 lactic acid/urea (Calmurid) and 4
moisturisers per month) are given to patient. Breakdown in supply of these creams to patient are a
common cause of recurrence.
nly benzyl benzoate should be used for regular preventative treatment (regular use of permethrin or
O
ivermectin can lead to development of resistance).
atients should not share a bed and should have a hospital grade mattress which can be easily cleaned
P
(where possible).
atients at high risk of re-exposure to scabies are those living in a house with many occupants especially
P
young children.
n intensive phase of clinic involvement is important to show the patient and household the benefit of
A
adherence to the chronic care plan (e.g sleep).
The patient’s seniority in the house is critical. More support is needed for patients without seniority.
*The ultimate goal should be self-care and management with clinics supplying creams and conducting
skin checks.
47
Appendix 4
4 CHRONIC
CARE PLAN
Ongoing management
Ongoing management is required after a full treatment for crusted scabies as per guidelines and
where an excellent response has occured with no evidence of residual active scabies.
Risk of
Frequency of
Preventative
recurrence and
How to grade
skin checks
treatments
severity
Low - Moderate
Low infectivity:
Monthly
Crusts isolated and
discrete patches — less
than 5% Total Body
Surface Area (TBSA).
Skin: Minimal shedding
chronicity 0–3 prior
hospitalisations for
crusted scabies.
(examine skin
including buttocks)
2. A
pply benzyl
benzoate as needed
if exposed to scabies.
Consider supervision
of benzyl benzoate.
Fortnightly
High infectivity:
Crusts lower legs,
buttocks, trunk OR
10% or more of TBSA
Skin: Current or past
heavy shedding.
High
AND chronicity :
ore than 3 prior
M
hospitalisations for
crusted scabies.
And/or depigmentation
of legs/back or residual
skin thickening/ scaly
skin (ichthyosis).
1. E ncourage regular
use of lactic acid/
urea (Calmurid)
and moisturiser on
areas affected by
past crusting.
(examine skin
including buttocks)
1. E ncourage regular
use of lactic acid/
urea (Calmurid)
and moisturiser
on areas affected
by past crusting.
2. A
pply benzyl
benzoate from neck
down fortnightly.
3. A
s needed apply
benzyl benzoate
immediately to
any areas exposed
to scabies (e.g.
hands after visit
of affected person).
48
Appendix 4
4 CHRONIC
CARE PLAN
Recurrences are to be expected
Detect, treat early and don’t get disillusioned.
Problem-solve with the family as they are part of the treatment team.
Common causes of recurrence include:
- Not treating all contacts.
- Failure to apply creams to hard to reach areas, especially buttocks.
- Running out of supplies of preventative creams.
- Visitors with scabies re-introduce the disease to the household.
Offer more scabies cream and promote their use with all household contacts.
onsider repeating household treatment and expanding it to include closely related households that
C
could be the source of re-infection.
If scabies persists speak to the One Disease team for program guidance.
At this stage it is more important than ever not to blame the family. In these cases there is normally
something else going on and if that can be resolved the scabies will often be fixed by the family
themselves. This may just take time and patience.
If many household have scabies consider a Healthy Skin Day. See CDC Healthy Skin Program Guidelines
and/or call One Disease for advice.
49
Appendix 4
FOR MORE
INFORMATION
For clinical advice consult the CARPA Standard Treatment Manual or infectious diseases specialists via the
switchboards of Royal Darwin Hospital on 08 8922 8888 or Alice Springs Hospital on 08 8951 7777.
For information on this document contact One Disease www.1disease.org or [email protected]
Useful Scabies Resources
NT CDC Healthy Skin Program Guidelines (planning a healthy skin day)
http://www.health.nt.gov.au/Centre_for_Disease_Control/Publications/CDC_Protocols/index.aspx
Flipchart – recognising and treating skin conditions (Menzies)
http://www.menzies.edu.au/icms_docs/162092_Recognising_and_Treating_Skin_Conditions.pdf
Developed by program strategy and implementation consultants, EveryVoiceCounts and the One
Disease team.
Thanks to Prof. Bart Currie for expert advice and pictures used.
Approved by the medical reference group of the East Arnhem Scabies Control Program.
.org
MORE INFO | MANAGING CRUSTED SCABIES IN REMOTE ABORIGINAL COMMUNITIES | 2014 EDITION | 21
50
Appendix 4
51
Territory
Appendix 5 Educational resource list
TITLE
WHAT
SOURCE
Managing Households With
Recurrent Scabies
eBook
One Disease
http://1disease.org/wpcontent/uploads/2014/07/Recurrent
-Scabies-guide-2014_final1.pdf
Managing Crusted Scabies
in Remote Aboriginal
Communities
eBook
CARPA Standard Treatment
Manual
Healthy Skin Story
Scabies
Book
One Disease
http://www.healthinfonet.ecu.edu.a
u/uploads/resources/27857_27857.
pdf
Centre for Remote Health
Flipchart
http://www.healthinfonet.ecu.edu.au/keyresources/promotion-resources?lid=18932
Recognising and Treating Skin Flipchart
Conditions
http://www.menzies.edu.au/page/Resources/R
ecognising_and_treating_skin_conditions/
Scabies
Fact sheet
NT Centre for Disease Control http://www.health.nt.gov.au/library/script
s/objectifyMedia.aspx?file=pdf/47/10.pdf
&siteID=1&str_title=Scabies.pdf
Scabies prevention
and treatment
Information
Sheet
Scabies and other
mites causing skin
disease
Fact sheet
Fact sheet South Australian Health
Staying Healthy in Child Care 5th
edition
http://www.nhmrc.gov.au/_files_nhmr
Further information is available from One Disease | Menzies Building
RDH Campus , Rocklands Drive Tiwi NT 0810
+61 448 071 503 | www.1disease.org
52
Territory
Appendix 6 Equipment list for community screening
and treatment
General
•
•
•
•
•
•
•
•
•
Community population list
Screening spread sheet
Pens/paper
Sharps container
Alcohol swabs
Needles and syringes
Gloves
Hand wash
Scales
Scabies and skin sores treatment
•
•
•
•
•
•
Permethrin cream (Lyclear)
~ 1 tube for 2 adults
~ 1 tube for 4 children
~ 1 tube for 8 babies
Crotamiton cream (Eurax)
Benzathine penicillin G (2.3mL) – store in esky to maintain temperature between 2–8o C
53
Guidelines for the Community Control of Scabies, Skin Sores, Tinea and Crusted Scabies in the Northern Territory
Yes / No
required
Yes/ No
Yes / No
Yes / No
sores
skin
Checked
Name
DOB
Date
Scabies
Infected
BPG given
Follow up
Appendix 7 Example spreadsheet for baseline screening
54
Appendix 8 Baseline screening and community treatment
55
yes/no
yes/no
yes/no
yes/no
yes/no
yes/no
yes/no
yes/no
scabies
skin sores
skin sores
scabies
skin sores
date:
date:
scabies
skin sores
scabies
date:
date:
6 month follow up
Name
DOB
3 month follow up
9 month follow up
12 month follow up
Appendix 9 Example spreadsheet for ongoing
surveillance
56
Territory
Appendix 10 Maintenance program
57
Territory
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59
Guidelines for Community Control of Scabies, Skin Sores,
Tinea and Crusted Scabies in the Northern Territory
Northern Territory Department of Health

Healthy Skin Program - Department of Health

Transcription

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